Although the US has now joined 30 countries in requiring all cigarette packets to display gruesome images of the results of diseases caused by smoking, Deputy Health Minister Ya'acov Litzman (United Torah Judaism) has "not yet decided his position," an aide said. Use of the graphic displays is being strongly urged by the World Health Organization's Framework Convention on Tobacco Control, which Israel has ratified. Putting such images on packets has been proven in scientific research to lower smoking rates significantly, with many smokers getting the message and their children, spouses and friends demanding that they kick the habit. Images appearing around the world include a mouthful of yellowed, rotten teeth; blackened lungs; gangrenous feet; a dead fetus lying near cigarette butts; a hole in the throat, in addition to bold texts such as "WARNING: Smoking can kill you," and "Tobacco smoke can harm your children." Countries featuring the warnings include Canada, the UK, Singapore, China, Brazil, Austria, Germany, Finland, the Czech Republic, New Zealand, Australia, Panama, Thailand, Romania, France, Hungary, Jordan and Iran. "His schedule is packed," Litzman's personal aide Ya'acov Izak told The Jerusalem Post on Wednesday. "The deputy minister has not yet formulated his position on the issue, and it has not been officially discussed in his office. When it is raised and discussed, he will decide. He has not said he is opposed to it." Litzman, who told the Post upon entering office that he opposes smoking, quickly pushed for and succeeded in raising tobacco taxes by a small amount, but he has not taken additional action since. He is regarded by some leading smoking-control advocates as "dragging his feet" on major initiatives to reduce the smoking rate, which has remained steady at 24 to 25 percent of Israelis over 18 for the last two years and even increased slightly. They said they hope the powerful tobacco lobby has not managed to persuade him to remain passive on the issue. Some legal experts believe graphic images could be instituted by the minister via an administrative order, without new legislation. If Litzman does not move quickly, the smoking-control advocates say they intend to persuade a pro-health MK to initiate a private member's bill that would require use of the graphic displays. Israel Cancer Association director-general Miri Ziv said the Israel National Council for the Prevention of Smoking, which includes Health Ministry public health experts, has come out strongly in favor of such warnings. "Requiring graphic images is a broad consensus among them. It has been shown that pictorial messages are three times more effective in persuading people to quit smoking - or never to start - than text," Ziv said. President Barak Obama - who admits to smoking occasionally when his wife is not around - recently signed the Family Smoking Prevention and Tobacco Control Act passed by Congress that will require tobacco products sold in the US to cover half of the front and rear panels of packages with color graphics showing what happens when you smoke, and bold labels with texts. Since 1985, the US warning has consisted only of a small-font warning from the surgeon general that smoking by pregnant women may result in fetal damage. In 1965, the US forced tobacco companies to print: "Cigarette Smoking May Be Hazardous to Your Health" on their products in small print, though gradually the wording became more insistent and the amount of space was increased. But foreign public health experts maintain that the texts were largely ignored by smokers - especially illiterates and children - and that graphic images were needed. In 2000, Canada was the first country to require graphic warnings showing mouth cancer on tobacco products. "It's the one that smokers remember more than anything else, even after nine years," said University of Waterloo (Ontario) health researcher Dr. David Hammond. Last week, a university review article written by Hammond and Waterloo psychology Prof. Geoffrey Fong and published in the August 1 issue of the WHO Bulletin stated, "Substantial evidence from a broad range of studies supports the inclusion of graphic pictorial images on tobacco warning labels. Our research findings show that graphic pictures can enhance the effectiveness of warning labels by making them more noticeable, increasing thoughts about the hazards of smoking and increasing motivation to quit." Smoking remains by far the biggest killer in Canada, with 37,000 dead each year; the toll in Israel is 10,000, and in the US, 440,000. In the 20th century, 100 million people around the world died from tobacco use, and Fong predicts that it will reach a billion in the 21st century, especially in low- and middle-income countries. Some smoking-cessation activists have suggested a requirement of printing a pictogram directly on the cigarette itself and on equipment used for water-pipe smoking. Package warnings reach the entire population, according to Rob Cunningham of the Canadian Cancer Society. "They provide mass public education and work 24 hours per day, seven days per week. A consumer may take out a package 20 times per day, about 7,300 times per year. Packages can have an impact on both consumers and non-consumers. A picture does indeed say a thousand words," he said. In May, the WHO chose pictorial warnings as the 2009 theme for World No-Tobacco Day. "The tobacco industry itself uses pictures in its advertising and on packages. If the industry uses pictures to promote tobacco use, how can the industry credibly object when health departments want to use pictures to discourage tobacco use? "But the industry continues to actively lobby against larger picture-based warnings in many countries. Obviously, it knows that picture warnings will have an adverse impact on overall sales," Cunningham concluded.